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Based on record review and staff interview, it was determined that the admitting physician and the hospital staff failed to comply with and adhere to regulatory requirements and hospital policy related to the patient ' s right to be informed of his/her health status; and to be involved in his/her plan of care and treatment. Patient # N1.

The findings included:

In accordance with the previously cited federal regulation and the State regulation 22 DCMR 2022.2, referencing ' Patient Rights ' : the hospitals must establish and implement a process to provide the patient and/or patient ' s representative appropriate education/information to assist him/her in understanding his/her identified clinical condition, diagnosis and prognosis; and the necessary care and treatment. The regulations further stipulate that the information should be provided in a manner that the patient or representative can understand.

The Medical Staff General Rules and Regulations, last revised and approved by the Hospital Board of Directors June 23, 2011, included the following directive statement under Article 1, Section 1.1 (e), titled ' Admission of Patients ' : " ...The patient shall be provided with pertinent information regarding outcomes of diagnostic tests, medical treatment and surgical intervention. "

Additionally, Hospital Policy # ADM 02-001, entitled ' Patient Rights and Responsibilities ' , last revised July 2011, included the following directives under " Section A. Patient Rights Include " : " Be informed about the outcomes of care, including unanticipated outcomes; Obtain complete and current information from your doctor concerning your condition and treatment; Know the reason you are given various tests and treatment; Know the nature and risks of procedures and treatments prescribed for you; and, Participate in the planning of your medical treatment through discussions with your health care team. "

Patient # N1 initially presented to the Emergency Department (ED) on February 15, 2012 complaining of a progressive onset of weakness, headache, blurred vision, imbalance, and abdominal pains with nausea and dry mouth for approximately two (2) weeks. The patient also admitted to an associated history of polyuria and polydipsia for one (1) month. He/she denied any significant past medical history and was not on any prescribed medications. The patient further acknowledged that he/she had not been seen or evaluated by a medical doctor " in a long time " .

Investigative clinical work-up in the ED determined that the patient had a diagnosis of New-Onset Diabetes Mellitus with Hyperglycemia. The patient was subsequently admitted to the hospital for continued in-patient clinical evaluation and treatment to stabilize his/her uncontrolled Diabetic disorder.

A review of the medical record was completed for the entire hospital stay from February 15, 2012 through February 17, 2012.

According to nursing progress note entries dated February 17, 2012 between 3:00 PM and 4:00 PM (block-timing entered), the patient became upset and agitated, requesting staff to contact his/her attending physician.

Subsequent interview with the administrative nursing supervisor covering the unit on which the patient was admitted; and interview with the patient revealed the following:

The nursing supervisor acknowledged that the patient was very frustrated. She stated that Patient # N1 continually expressed a need to speak with his/her primary care physician, saying he/she was dissatisfied with the care. The nursing supervisor went on to state that the patient verbalized anxiety and concern that hospital staff were constantly in and out of his/her room performing different tests and procedures which he/she did not understand and staff did not explain; and, that he/she needed his/her physician to fully explain " what he/she was being treated for and why " .

Telephone interview with Patient # N1 on March 13, 2012 at approximately 2:25 PM corroborated the following:

The patient stated he/she was never informed of the seriousness of his/her diagnoses and its potential medical and/or physical implications; was only told that he/she had " sugar " ; stated was never informed that his/her blood glucose levels were in critical ranges, until he/she had become frustrated and " was leaving out the door " ; had expressed frustration and dissatisfaction to the nursing staff on several occasions, and had requested that the primary physician of record be called. Patient # N1 also stated that " people were coming in one behind the other " , but no one was explaining what they were doing or why.

Patient # N1 concluded by stating that he/she had become so frustrated with the staff ' s lack of regard for his/her request to speak with the primary care physician concerning his/her medical condition, that he/she finally decided to leave the hospital and go to another acute care facility for treatment.

The medical record review revealed that Patient # N1 left the hospital at 5:20 PM on February 17, 2012 without an official medical discharge; without completing his/her medical treatment; and, without the prior knowledge of the medical team of physicians.

A face-to-face interview was subsequently conducted with the hospital ' s Medical Director on March 14, 2012 at approximately 1:00 PM. After discussion and review of the patient ' s medical record, the medical director acknowledged that " more should have been done to care for the patient and (his/her) needs " ; and that " clearly the ball was dropped " . The record review and complaint investigation was done March 14, 2012.

Based on record review and staff interview, it was determined that the admitting physician and the hospital staff failed to comply with and adhere to regulatory requirements and hospital policy related to the patient ' s right to have his/her physician notified promptly of his/her admission to the hospital. Patient # N1.

The findings included:

In accordance with the federal regulation cited, the hospital must ask the patient whether the hospital should notify his/her own physician. And, if the patient requests notice to and identifies the physician, the hospital must provide such notice promptly to the designated physician, regardless of whether the admission was scheduled in advance or emergent.

Hospital Policy # ADM 02-001, entitled ' Patient Rights and Responsibilities ' , last revised July 2011, acknowledged the federal regulatory requirement and included the following directive under " Section A. Patient Rights Include " : " The right to have his/her own physician promptly notified of his/her admission. "

Patient # N1 initially presented to the Emergency Department (ED) on February 15, 2012 complaining of a progressive onset of weakness, headache, blurred vision, imbalance, and abdominal pains with nausea and dry mouth for approximately two (2) weeks. The patient also admitted to an associated history of polyuria and polydipsia for one (1) month. He/she denied any significant past medical history and was not on any prescribed medications. The patient further acknowledged that he/she had not been seen or evaluated by a medical doctor " in a long time " .

Investigative clinical work-up in the ED determined that the patient had a diagnosis of New-Onset Diabetes Mellitus with Hyperglycemia. The patient was subsequently admitted to the hospital for continued in-patient clinical evaluation and treatment to stabilize her uncontrolled Diabetic disorder.

A telephone interview conducted with the patient on March 13, 2012 at approximately 2:25 PM revealed that at the time of his/her hospital admission, Patient # N1 informed and provided the hospital with the name of his/her primary care physician (PCP) of record. Review of the Emergency Department Triage form documented and confirmed hospital acknowledgment of the identity of the patient ' s PCP.

However, the patient indicated that he/she was placed under the care of another physician. He/she confirmed that the only encounter with this admitting physician was on the morning following his/her admission to the hospital. The patient indicated that during his/her meeting with the admitting physician, he/she informed and supplied the physician with the name of his/her PCP and had requested that the doctor be called and notified of his/her admission. However, he/she stated that the admitting physician resisted the request and remarked: " I ' m your primary physician ' s boss " .

The patient also stated that he/she had made several requests of the hospital staff to communicate with her PCP and inform him/her of admission to the hospital. Interview with the administrative nursing supervisor on March 14, 2012 at approximately 11:40 A.M. corroborated this account.

Concurrent review of the medical record, completed for the entire hospital stay from February 15, 2012 through February 17, 2012, supported the allegations of the patient in that the record lacked documented evidence that either the admitting physician or the hospital staff complied with the patient ' s right and repeated requests and promptly notified his/her physician of the hospital admission.

A face-to-face interview was conducted with the Vice President of Quality and Regulatory Compliance on March 14, 2012 at approximately 1:35 PM. After discussion and review of staff interviews and record review, he/she acknowledged and verified the aforementioned findings.

Record review was completed on March 14, 2012.

Based on record review and staff interview, it was determined that the medical staff failed to consistently comply with and enforce all areas of the Medical Staff By-Laws, to include adherence to its Rules and Regulations, as evidenced by the following: failure of the admitting physician to execute responsibility for managing and coordinating the care and treatment of one (1) patient who was released from the hospital without a proper medical discharge and with a medically unstable clinical condition. Patient # N1.

The findings included:

The Medical Staff General Rules and Regulations, last revised and approved by the Hospital Board of Directors June 23, 2011, included the following directive statements under Article 1, Section 1.1 (e), titled ' Admission of Patients ' : " The management and coordination of each patient ' s care, treatment and services shall be the responsibility of a Physician with appropriate Privileges. Each Medical Staff Member shall be responsible for the medical care and treatment of each of his/her hospitalized patients, for the prompt completeness and accuracy of the medical record ...and, for necessary special instructions. "

Additionally, Section 1.5 (a), titled ' Discharge of Patients ' stipulated and included the following directive: " Patients shall be discharged only on order of the Attending Physician. Should a patient leave the hospital against the advice of the Attending Physician or without proper discharge, a notation of the incident shall be made in the patient ' s medical record by the Attending Physician. The discharge process and corresponding documentation shall provide for continuing care based on the patient ' s assessed needs at the time of discharge. "

The hospital ' s Health Information Policy # HIM 6.076, titled ' Medical Records Guidelines for Physicians ' , last revised August 2011, included the following directives under the ' Discharge Summary ' section: " Final progress {note} may be substituted for a discharge summary if the patient was hospitalized less than 48 hours for a minor problem (does not include deaths) ...Final progress note should include instructions to the patient and/or family. "

Patient # N1 initially presented to the Emergency Department (ED) on February 15, 2012 complaining of a progressive onset of weakness, headache, blurred vision, imbalance, and abdominal pains with nausea and dry mouth for approximately two (2) weeks. The patient also admitted to an associated history of polyuria and polydipsia for one (1) month. He/she denied any significant past medical history and was not on any prescribed medications. The patient further acknowledged that he/she had not been seen or evaluated by a medical doctor " in a long time " .
Investigative clinical work-up in the ED determined that Patient # N1 had a diagnosis of New-Onset Diabetes Mellitus with Hyperglycemia. The patient ' s initial chemistry panel laboratory studies, performed on February 15, 2012, revealed a critically elevated Blood Glucose level of 1291mg/dL {normal range: 65-99 mg/dL}; and, an elevated Hemoglobin A1C percentage of 12.3 % {normal range: 4.5-6.1 %}. The patient was subsequently admitted to the hospital for continued in-patient clinical evaluation and treatment to stabilize his/her uncontrolled Diabetic disorder.
Review of the medical record revealed that on February 17, 2012 at approximately 5:20 PM, Patient # N1 left the hospital without an official discharge, without completing his/her medical treatment, and, without the prior knowledge of the admitting physician. The medical record officially listed the patient ' s release from the hospital as Against Medical Advice (AMA).

Interview with the administrative nursing supervisor on March 14, 2012 at approximately 11:40 AM revealed that prior to his/her unauthorized release from the hospital, the patient had expressed frustration and dissatisfaction to the nursing staff at not being able to speak with his/her PCP. Review of the nursing notes revealed that the admitting physician had not visited with the patient on February 17, 2012 nor had he/she responded to several hospital communication pages sent by the staff beginning at 3:00 PM.

Continued review of the interdisciplinary patient progress notes revealed that the admitting physician did not respond to hospital pages until approximately 6:20 PM. At that time, he/she was made aware of Patient # N1 ' s unauthorized discharge from the hospital.

The record review further revealed that the admitting physician failed to document a concluding progress note detailing the events concerning the patient ' s AMA incident, as required by the Medical Staff and hospital regulations. Furthermore, given the severity of the patient ' s unstable clinical condition, the admitting physician also failed to provide documentation in the medical record, to ensure that continued, on-going medical care provisions had been prescribed and/or secured for the patient. There was no evidence that the admitting physician ever attempted to contact the patient to inform him/her of the severity of his/her untreated medical illness and the necessity to seek continued treatment for his/her medical diagnoses.

The medical record confirmed that the admitting physician did not document any subsequent progress notes related to the patient ' s care, management or disposition, apart from the initial Admission H&P; nor did he/she document a final progress note or discharge summary after the patient ' s unauthorized discharge and release from the hospital.

A face-to-face interview was conducted with the Vice President of Quality and Regulatory Compliance on March 14, 2012 at approximately 1:45 PM. After discussion and review of staff interviews and record review, he/she acknowledged and verified the aforementioned findings.
Record review was completed on March 14, 2012.

Based on record review and staff interview, it was determined that the hospital nursing staff failed to effectively evaluate and intervene for the care needs of one (1) patient, as evidenced by the following: failure to implement hospital policies to avoid the unauthorized and unsafe discharge of the patient with incomplete treatment for unstable Hyperglycemia. Patient # N1.

The findings included:

In accordance with Title 17 District of Columbia Municipal Regulations (DCMR) for Registered Nurses, Chapter 54, Section 5414, titled ' Scope of Practice, the following directives were included under subsections 5414.1(c): " The practice of registered nursing means the performance of acts requiring substantial specialized knowledge, judgment, and skill based upon the principles of the biological, physical, behavioral, and social sciences in the following: (c) The performance of services, counseling, advocating, and education for the safety, comfort, personal hygiene, and protection of clients, the prevention of disease and injury, and the promotion of health in individuals, families, and communities, which may include psychotherapeutic intervention, referral, and consultation. "

The hospital ' s administrative policy # ADM 04-023.1, entitled ' Patients who leave the Hospital Against Medical Advice (AMA) ' , last revised June 2009, included the following ' Procedure ' directives: " The attending physician will be notified immediately when a patient expresses the desire to leave the Hospital; the patient is informed of the risks of leaving the Hospital; if the attending physician is not physically in the hospital, obtain any post-hospitalization instructions at this time; document the reason the patient left AMA and the discussion with the patient in the medical record. "

The Medical Staff General Rules and Regulations, last revised and approved by the Hospital Board of Directors June 23, 2011, included the following directive statement under Article 1, Section 1.1 (f), titled ' Admission of Patients ' : " In cases of inability to contact the attending physician, the following should be contacted, in order of priority listed below: (1) An alternative Physician (preferably a partner, associate or designee of the attending physician), Hospitalist, Department Chairperson, Chief of Staff, CEO; (2) The Chief of Staff, who may assume care for the patient or designate any appropriately trained Member of the staff; or (3) In the absence of the above, any appropriately trained Member of the Medical Staff requested by the CEO to provide care for the patient. "

Furthermore, the hospital ' s administrative policy # ADM 04-009, entitled ' Chain of Command ' , last revised April 2008, reflected and verified the same directive procedures identified in the aforementioned Medical Staff General Rules and Regulations concerning measures to be adopted in cases of inability to contact the attending physician.

Patient # N1 initially presented to the Emergency Department (ED) on February 15, 2012 complaining of a progressive onset of weakness, headache, blurred vision, imbalance, and abdominal pains with nausea and dry mouth for approximately two (2) weeks.

Investigative clinical work-up in the ED determined that the patient had a diagnosis of New-Onset Diabetes Mellitus with Hyperglycemia. The patient was subsequently admitted to the hospital for continued in-patient clinical evaluation and treatment to stabilize her uncontrolled Diabetic disorder.

On February 17, 2012, the nursing notes reflected that the patient had become upset and agitated and had requested to speak with his/her physician. Continued review of the nursing notes revealed that the admitting physician had not visited with the patient on February 17, 2012 nor had he/she responded to several hospital communication pages sent by the staff beginning at 3:00 PM.

At 4:00 PM, the evening shift nursing staff documented the following events: " ...Patient wants the IV (Intravenous access) out that she ' s gonna leave the unit and told her that she has to sign AMA (against medical advice) form and she said " I ' m not gonna sign any papers " . Nursing supervisor made aware and charge nurse made aware. IV removed per patient ' s request. "

The medical record confirmed that the patient left the hospital at 5:20 PM on February 17, 2012.

However, continued review of the medical record and subsequent interview with supervisory nursing personnel revealed the following findings relative to the patient ' s release from the hospital:

There was no corroborating nursing note entry to demonstrate that the nursing staff had documented and included evidence of a discussion and/or dialogue exchange with Patient # N1 stating the reason or explanation as to why he/she decided to leave the hospital.

There was furthermore no documented evidence that the admitting physician, the hospitalist, or any other healthcare worker consulted with and/or advised the patient of the possible risks of leaving the hospital prior to completing treatment and diagnostic evaluation for his/her identified clinical condition. There was also no documented evidence from any Licensed Independent Practitioner certifying that Patient # N1 was clinically stable for safe discharge and release. And, finally, there was no documented evidence that the patient was provided with post-hospitalization instructions for follow-up and the necessity for continued medical care, at the time of his/her unauthorized release.

According to the nursing supervisor, he/she was called to the nursing unit to speak with Patient # N1 as a result of the patient ' s expressed verbal intents on leaving the hospital. The nursing supervisor acknowledged that the patient was frustrated and was " already getting dressed " to leave when he/she entered the room. Upon inquiry with the patient, the nursing supervisor determined that the patient needed his/her physician to fully explain " what he/she was being treated for and why " .

The nursing supervisor was subsequently queried concerning the failure of the admitting physician to respond to hospital page alerts; staff ' s awareness of the hospital ' s policy related to ' Chain of Command ' ; and the hospital ' s practice and/or expectation concerning discharge instructions when patients leave AMA.

The following findings were determined as a result of the query response and discussion with the nursing supervisor: The supervisor acknowledged that even after the failure of the admitting physician to respond, the staff did not make any attempts to communicate with any other physician or the covering hospitalist to advise them of the patient ' s request, intent on leaving the hospital, and his/her unstable clinical condition. The nursing supervisor also admitted that he/she did not direct the staff further in the proper procedure to adopt in cases of inability to contact the attending physician; nor did he/she administratively intervene and implement the physician chain of command to address the failure of the attending physician to respond to the hospital ' s page alerts.

Concerning the hospital ' s practice and/or expectation related to discharge instructions when patients leave AMA, the nursing supervisor stated, " We still attempt to give a discharge plan " .
However, he/she confirmed that Patient # N1 did not receive any instructions upon discharge; nor did the patient receive pertinent follow-up medical guidance related to the urgency to seek continued treatment for the incomplete management of his/her newly diagnosed clinical condition.

A face-to-face interview was conducted with the Vice President of Quality and Regulatory Compliance on March 14, 2012 at approximately 1:50 PM. After discussion and medical record review, he/she acknowledged and verified the aforementioned findings. Record review was completed on March 14, 2012.